NOTICE OF TRANSFER OF PATIENT IN THE MATTER OF:

TRANSFERRED FROM:_____________________ Treatment Facility

______________________ Patient

______________________ Court Case Number

TRANSFERRED TO:______________________ Treatment Facility or Program

To the District Court of ________________, County, State of Utah, and to the law firm of:___________________________________________________________ (patient’s legal counsel of record)

Record the specific place of residence where this patient can be located at the time for the next court review of commitment status: ADDRESS:_____________________________________________________ _____________________________________________________ City

State

Phone

The above transfer was made on the _____ day of _____________, 20_____. The judicial order of commitment is still intact. Dated this _____ day of ____________, 20_____. ________________________ Signature of Director or Designee

________________________ Title

DSAMH Form 41 Revised 2012